The Real Problem With Medical Internships Sandeep Jauhar
Sandeep Jauhar JULY 1, 2015
Credit Erik Carter
APPROXIMATELY 26,000 newly minted doctors across the United States will begin their internships today. For many, this legendarily grueling year will be the most trying time of their professional lives. Most will spend it in a state of perpetual exhaustion, as near ascetics with regard to family, friends and other pleasures. I was an intern nearly 20 years ago, but I still remember it the way soldiers remember war.
Fortunately for today’s interns, regulations have since reduced some of the misery. Most interns now are not permitted to work shifts longer than 16 hours. They are also encouraged to nap while on overnight duty.
At first glance, such reforms make sense. Studies have found that doctors who got no sleep during a night on call scored lower on tests of simple reasoning, response time, concentration and recall. Indeed, a single night of continuous sleep deprivation has been shown to be roughly equivalent to having a blood alcohol level of 0.10 percent — that is, being drunk.
But there is a downside to these regulations. Limits on work hours lead to frequent patient handoffs, which are susceptible to breakdowns in communication between doctors, thus potentially creating errors. In aviation, most crashes occur on takeoff and landing, and in medicine, too, most mistakes happen during transitions.
Is it better to be cared for by a tired intern who knows your case or a rested intern who does not? Though some studies have shown that interns working traditional long hours (shifts of 24 hours or more) make more mistakes than those working reduced hours, others have shown that work-hour limits cause delays in tests and other preventable complications. In fact, a recent study in the Journal of the American Medical Association found no evidence that new reductions in work hours improved the quality or safety of patient care.
Patient safety is also heavily influenced by the number of patients that interns are responsible for. Because interns’ patient loads have not decreased (and have probably increased) in recent years, rigid work-hour restrictions may also be aggravating safety problems by compressing work into shorter shifts.
Long hours and hard work have been features of medical training since the modern residency program had its beginnings at the Johns Hopkins Hospital in Baltimore in the late 19th century. As the medical historian Kenneth M. Ludmerer details in his recent book “Let Me Heal,” an authoritative account of the residency system in the United States, teaching hospitals and medical residents have always had an implicit contract: Hospitals provide patients (often indigent ones) on whom young doctors learn their craft; in return, young doctors provide cheap labor to keep these institutions running.
“The only thing that has changed,” Dr. Ludmerer told me recently, “is the nature of the exploitation.” In earlier generations, he explained, young doctors were saddled with considerable manual chores — drawing blood, inserting intravenous lines, transporting patients and so on. In the past two decades, these chores have been replaced by a new kind of scut work: treating a large number of patients (to help maintain hospital “throughput”) while juggling an expanding load of administrative chores.
This workload has become even harder to manage because of rules — designed to provide respite — that mandate that interns must leave the hospital immediately after completing a shift. Rushing to finish their work can cause interns to make mistakes and order unnecessary tests to compensate for a lack of time to think through a difficult case.
These enforced work shifts also interrupt learning and create a kind of clock-watching mentality that is antithetical to the ideals of doctoring. I once worked with an intern who refused to take a patient having an acute stroke for a CT scan because it was the end of her shift and she was ready to leave.
Interns and residents must experience a broad range of clinical situations before they can become competent, independent physicians. I believe that they should be allowed to stay at a sick patient’s bedside or attend a teaching conference after completing a work shift if they are so inclined. Compressing a heavy workload into fewer hours serves no one’s interests. Combining the complexity of today’s patient care with work-hour restrictions may actually lead to more burnout among trainees.
Of course, we must end the exploitation of interns and residents by teaching hospitals. Hospitals should hire more physician assistants to relieve young doctors of the routine work and heavy patient loads with which they are still burdened. Residency directors should give interns more research opportunities to foster scholarship so that postgraduate training doesn’t devolve into mere vocational instruction.
But rigid work-hour limits are not the answer to the ills of internship. In trying to get interns a bit more rest, we may have come up with a cure that is worse than the disease.
Sandeep Jauhar, a cardiologist and a contributing opinion writer, is the author of “Doctored: The Disillusionment of an American Physician” and “Intern: A Doctor’s Initiation.”